The Journal of School Nursing2022, Vol. 38(1) 48–60© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211045693journals.sagepub.com/home/jsn
School-based asthma programs have been proven to lessen the burden of pediatric asthma. There is a lack of successful care coordination between school nurses and primary care providers. This review examined strategies to increase communication and identified gaps in the literature. Databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and The Cochrane Library, were searched to identify relevant articles. This review included 12 articles consisting of randomized controlled trials, quasi-experimental studies, mixed method studies, qualitative studies, and other non-research articles. Four key findings emerged, including limited availability of asthma action plans, inclusion of parents in the communication triad, school nurse outreach to providers, and improved communication leads to positive outcomes for students with asthma including decreased use of emergency medication and increased self-management of asthma. Further research is needed to develop evidence-based interventions that can be implemented to improve communication between school nurses and primary care providers
asthma, community, school Nurse Education, integrative Reviews, communication
Asthma is one of the most common chronic illnesses in pediatrics, affecting 7.5% of United States youth (CDC, 2018). Children with uncontrolled asthma experience a number of challenges, including decreased participation in physical activity, increased time and money spent on medications, clinic and emergency department visits, and hospitalizations (Snieder et al., 2017). One strategy to lessen the burden of pediatric asthma is to include school nurses in care coordination as they have frequent contact with these children. Many children do not see a primary care provider regularly for well-child visits, and so school nurses are often their primary health resource (Snieder et al., 2017). School-based asthma programs can vary in what and who they include, but typically include case management, care coordination, and age-appropriate self-management education programs for students with asthma (Gleason et al., 2016). School-based management of asthma has its own challenges, including a lack of communication between school nurses and primary care providers (PCPs) (Pappalardo et al., 2019).
The importance of communication between school nurses and PCPs is based around the concept of care coordination. Care coordination is defined as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services” (McDonald et al., 2007). The Agency for Healthcare Research and Quality (AHRQ) listed care coordination as one of six priorities of the National Quality Strategy due to the significant improvement in patient outcomes with successful coordination (AHRQ, 2015). Regarding school health specifically, The National Association of School Nurses (NASN) describes school nurse-led care coordination as a teambased approach including communication between the school nurse, parents, and the health care provider. The goal is to provide effective management of chronic health conditions to allow the child to be healthy and ready to learn (NASN, 2019). Students with chronic illness who receive care coordination have been found to have improved health outcomes (Leroy et al., 2017; Moroccan et al., 2012). Unfortunately, only a small proportion of school nurses feel they have effective communication with health care providers about students with asthma (Pappalardo et al., 2019). The primary methods of communication between school nurses and health care providers are currently fax, phone and traditional mail (Baker & Gance-Cleveland, 2020). Despite electronic health records (EHRs) being standard in the hospital setting, they are not routinely being used to coordinate care with school nurses (Baker & Gance-Cleveland, 2020). While the eventual integration of school EHRs with health care providers EHRs would be ideal, there are currently legal and logistical barriers that prevent EHRs from being a solution to communication barriers (Baker & Gance-Cleveland, 2020).
School-based asthma programs have had generally positive results (Cheung et al., 2015; Cicutto et al., 2018; Engelke et al., 2013; Liberatos et al., 2013). These programs have the potential to increase asthma knowledge and quality of life and decrease rescue inhaler use, emergency department visits, nighttime symptoms, and school absenteeism (Gleason et al., 2016). Typically, communication barriers are one component addressed in studies on school-based asthma interventions. This integrative literature review will examine what strategies have been used to increase communication between school nurses and primary care providers and what gaps still exist in the literature.
A search of the literature was conducted related to the question, “how can communication between school nurses and primary care providers regarding students with asthma be improved?” The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram (Figure 1) documents the process of the literature search and selection of articles for this review (Moher et al., 2009). This comprehensive literature search was performed in September of 2020 and included four databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and The Cochrane Library. The search strategy utilized medical subject headings (MeSH) and related terms such as “school nursing” AND “asthma” AND “care coordination” OR “communication”. The original search had no limitations and resulted in 224 articles. Nine additional articles were identified by examining reference lists of relevant articles.
After the initial search, the author independently used ProQuest RefWorks to further organize articles and duplicate articles were removed leaving 208 titles. Articles were assessed by title and abstract based on their relevance to the project question. After inclusion and exclusion criteria were applied, thirty-four articles remained for full text review. Inclusion criteria were articles with a focus on communication or care coordination between school nurses and health care providers with a focus on asthma. Exclusion criteria included inability to access full text, non-peer reviewed journals, conference abstracts, and a non-pediatric population. Further exclusion criteria included non-US articles, articles that included chronic diseases other than asthma, articles with insufficient focus on communication between school nurses and providers, and studies that used consulting physicians or counselors instead of PCPs. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model was used to evaluate the articles for level of evidence and quality (Dang & Dearholt, 2017). All articles, regardless of level of evidence, were included in the review if they met the above-mentioned criteria.
Twelve articles published between 2006 and 2020 met the inclusion criteria for this review. Seven of the articles were qualitative, two were quantitative, and three were nonresearch. The three non-research studies included a consensus statement, quality improvement, and a literature review. Levels of evidence ranged from I to V. The quality of the evidence in 11 articles was rated A or B, and one study was rated C. Table 1 details the type of evidence, sample, sample size, setting, significant findings, observable measures, limitations, level of evidence, and quality for each article included.
Settings of the articles were all in the United States and included public school systems in the Northeast (NY, VT, MA, PA, CT), the Midwest (MN, MO), and the West (CO). The school systems locations ranged from urban to rural. The populations sampled in the twelve articles reviewed varied significantly, with four articles examining school districts without focusing on individual students, two articles focusing on elementary school students, one sampling middle school students, and three studies examining school nurses. Four key findings were identified through an inductive process regarding important aspects of communication between school nurses and providers. These include availability of asthma action plans (AAPs), inclusion of parents in communication triad, direct outreach to PCPs, and the effects of improved communication on outcomes. A visual representation of these key findings can be seen in Figure 2.
A key finding that persisted through six of the articles reviewed was the availability of documentation from the health care provider, specifically AAPs. An AAP is a document that serves as a communication tool for primary care providers and school nurses (Cicutto et al., 2018). It details management steps and may also authorize the school to administer necessary emergency medications as to not delay life-saving treatment (Cicutto et al., 2018). School nurses can utilize AAPs received from providers to develop individualized health plans that can be used within the school to notify various staff members about students with asthma. The articles discussed both ways in which school nurses may receive AAPs: through the parent, or directly from the health care provider. The general finding of the articles was that only a small percentage of students with asthma, approximately 10%, had an AAP available in the school (Frankowski et al., 2006; Pulcini et al., 2007). One mixed methods study with a nongeneralizable limited sample (n = 65) had a higher prevalence of AAPs at 43.2% (Hanson et al., 2013). Interventions aimed to increase the number of AAPs for children had conflicting results. Two studies demonstrated that direct communication between the school nurse and PCP increased the AAP prevalence rate by 40–60% (Frankowski et al., 2006; Pulcini et al., 2007). Studies that focused on communication between parents and providers, however, yielded lower return rates of AAPs at 10–15% (Bruzzese et al., 2006; Cicutto et al., 2018).
Another key finding that emerged was the inclusion of parents in care coordination for students with asthma. In the consensus statement included in this review from the School-based Asthma Management Program Workforce, PCPs, specialists, researchers, policy makers, patient advocates, and informaticians determined that two essential components for successful coordination of pediatric asthma care is to develop a circle of support around the child with asthma and to facilitate communication between clinicians and schools (Kakumanu et al., 2017). Building a circle of support includes establishing a relationship between a child with asthma and their family with the school nurse and clinician (Kakumanu e,t al., 2017). Inclusion of parents is imperative to successful care coordination as school nurses need consent forms signed by guardians of the child to exchange information with a student‘s healthcare providers (HCP) (Liberatos et al., 2013).
However, studies demonstrated lack of communication among parents, school nurses, and PCPs (Gleason et al., 2016; Hanson et al., 2013; Hollenbach & Cloutier, 2014; Liberatos et al., 2013). A mixed methods study revealed that 75% of nurses found lack of communication with parents to be a barrier to asthma management, and 45.5% of nurses identified lack of communication with providers to be a barrier (Liberatos et al., 2013). Additionally, frustration regarding communication with parents included a lack of returned provider signed medication order forms and missing consent from parents for the school nurse to exchange information with the PCP (Liberatos et al., 2013). Asthma care coordination should involve three-way communication between school nurses, parents and health care providers. However, the review identified there are deficiencies in each branch of communication.
Many of the studies reviewed showed that interventions are more successful when school nurses initiate communication with providers, rather than waiting for the provider to initiate, or talking to the provider through the child’s parents Studies varied in their results regarding the perceived amount of direct communication between school nurses and health care providers. Two studies identified this miscommunication to be a major barrier to pediatric asthma care (Hollenbach & Cloutier, 2014; Kakumanu et al., 2017). In contrast, one study found that 76% of school nurses reported very effective or effective communication with physicians (Volkman & Hillemeier, 2008). Studies that included interventions that involved direct communication with providers, regardless of what the specific intervention was, showed positive results. One study developed the Asthma Assessment Communication Tool for school nurses to easily report assessment data, symptoms, and information about medication compliance to the PCP (Cheung et al., 2015). This intervention was found to be a useful tool in facilitating communication regarding changes in a child’s asthma status (Cheung et al., 2015). Another strategy that was reported to be successful in facilitating asthma care was for school nurses to reach out to health care providers to explain the importance of the AAP (Frankowski et al., 2006).
The final key finding that emerged was how improving communication between school nurses and health care providers would affect outcomes of children with asthma. Three studies explored the effect of improved communication on asthma outcomes. One study implemented the Building Bridges for Asthma Care Program, which included education for parents and students along with care coordination activities (Szefler et al., 2019). Care coordination activities included school nurses requesting copies of school asthma care plans from health care providers and sending letters to health care providers about the student’s asthma control (Szefler et al., 2019). Results of the study found that the percent of students who needed to use a short-acting beta-agonist more than two times a week decreased from 35.8% to 22.9% (p < 0.01) when comparing the combined results of two intervention groups to case-matched control groups (Szefler et al., 2019). Another article discussed how partnerships between families, schools, and providers leads to improvements in self-management of asthma and selfefficacy skills such as access to quick relief inhalers at school (Gleason et al., 2016). Hollenbach and Cloutier’s literature review found that their reviewed studies showed improvements in asthma knowledge and reductions in school absenteeism (2014).
The reviewed literature regarding communication between school nurses and PCPs about students with asthma revealed four key findings that influence several recommendations. The majority of studies included in this review discussed communication as only a part of care coordination along with various other factors. There is a lack of research that focuses solely on communication. Because of this, many of the recommendations garnered from the review are more generalized as there was not enough evidence to recommend interventions specific to communication between school nurses and PCPs.
One of the main commonalities among the reviewed studies was the presence, or lack thereof, of AAPs (Bruzzese et al., 2006; Cicutto et al., 2018; Frankowski et al., 2006; Hanson et al., 2013; Pulcini et al., 2007). Majority of the studies that focused on AAPs found that only a small percentage of students with asthma had an AAP available at school (Bruzzese et al., 2006; Cicutto et al., 2018; Frankowski et al., 2006; Pulcini et al., 2007). The AAP is an evidence-based recommendation by an expert panel from the 2007 National Asthma Guidelines (Hanson et al., 2013). However, as shown by the reviewed studies, this recommendation is not consistently followed (Bruzzese et al., 2006; Cicutto et al., 2018; Frankowski et al., 2006; Hanson et al., 2013; Pulcini et al., 2007). AAPs are instrumental in facilitating communication between school nurses and PCPs as it efficiently provides necessary information regarding care of a child with asthma and encourages self-management (Hanson et al., 2013). Based on this information, it is the continued recommendation that all students with asthma have an AAP available in the school from a health care provider.
While the recommendation regarding the need for AAPs is supported by several studies, there is a lack of consensus on the best way in which to obtain this document. Currently, the primary methods of communication between school nurses and providers are faxes, phone calls, and traditional mail (Baker & Gance-Cleveland, 2020). Thus, productive bidirectional conversations about the importance or need for AAPs cannot be guaranteed (Snieder et al., 2017). Based on the research, it is more successful to have school nurses directly contact health providers to discuss the AAP rather than attempting to obtain the AAP from parents (Cheung et al., 2015; Frankowski et al., 2006; Hollenbach & Cloutier, 2014; ; Volkman & Hillemeier, 2008;). However, few studies investigated interventions specific to this concept. Meaningful use of electronic health record has also been touted as an effective approach to improve communication in real time between school nurses and primary care providers, enhance quality of care in a cost-efficient manner, and reduce errors (Johnson & Bergeron, 2011). The NASN in a position statement also recommends integration of electronic health record in school settings to allow school nurses to effectively coordinate care with the child’s PCP and other specialists (NASN, 2019). Another promising intervention was the Asthma Assessment Communication Tool to discuss changes in the child’s asthma status (Cheung et al., 2015). Additional research is indicated to further examine the Asthma Assessment Communication Tool and determine its effectiveness in multiple settings. It is important to also consider parental involvement when implementing any strategies related to the student’s asthma control as multiple studies showed that including parents in the communication process is imperative to care coordination (Kakumanu et al., 2017). By focusing on the partnership between the school nurse, families, and providers, asthma outcomes improve (Gleason et al., 2016),
The reviewed articles show that improved communication between school nurses and PCPs, regardless of the intervention that led to the improvement, has a positive effect on outcomes for students with asthma. Studies that implemented an intervention to improve care coordination led to improved self-management of asthma, improved asthma control, and reduced school absence rates (Gleason et al., 2016; Hollenbach & Cloutier, 2014; Szefler et al., 2019; Volkman & Hillemeier, 2008). These interventions included school nurses ensuring students with asthma had a primary care provider, communicating with providers about changes in a students’ asthma status, requesting forms to authorize schools to administer medication and AAPs, and providing education to the students’ about how to selfmanage their asthma (Gleason et al., 2016; Hollenbach & Cloutier, 2014; Szefler et al., 2019). Students with well controlled asthma can decrease the time and money spent on medications, clinic, and emergency department visits, and also improve academic outcomes (McCabe, 2020; Snieder et al., 2017). Based on this evidence, there is a clear recommendation to improve communication between school nurses and health care providers.
There were several limitations in this review. In the initial literature search, there were a lack of articles that focused only on communication between school nurses and PCPs on students with asthma. The articles included, while relevant, had a broader focus of care coordination that also included factors like parent and school staff involvement, education by school nurses for students with asthma, and other school specific tasks. The studies generally had a sub focus on communication, which made it difficult to differentiate the effects on communication alone from the effects on care coordination as a whole. Additionally, there was a wide variety of samples in the articles reviewed and the outcomes measured were not consistent across the studies. However, the different samples also benefitted the review in that it showed multiple perspectives on this topic which aided in narrowing down where the main barriers to communication lie. Additionally, the studies included had little discussion on the addition of self-management of asthma, which can be a part of school-based asthma programs. Self-management of asthma can lead to similar outcomes as discussed in this review, including increased quality of life and decreased emergency room and hospital visits (Harris et al., 2019). All of these limitations ultimately resulted in non-specific and non-generalizable interventions. Despite this, the review provides significant findings that will be beneficial in guiding future research.
This review provided several suggestions and recommendations related to communication between school nurses and primary care providers on students with asthma. Identified strategies to improve communication focus on how to increase direct contact between school nurses and providers regarding a student’s asthma status. Having an AAP for students with asthma and involving parents in the process contributes to developing a relationship between school nurses and PCPs which ultimately improves outcomes for students with asthma. There is still a gap in the literature on replicable interventions that are specific to communication and could significantly improve asthma control. Additional research is needed to determine potential evidence-based interventions to improve communication as well as clinical outcomes in individual students with asthma. Completion of this research has the potential to significantly improve asthma control and quality of life for children with asthma.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship and/or publication of this article.
Emma Slas https://orcid.org/0000-0001-6173-5287
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1 Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
Corresponding Author:Emma Slas, 525 N. Wolfe Street, Baltimore, MD 21205Email: Eslas1@jh.edu
